Atmosphere Yes No
Attractive appearance outside
Attractive appearance inside
Residents socialize with each other and appear happy and comfortable
Staff is appropriately dressed
Staff is personable and outgoing and helpful
Staff act in a professional manner
Visits with residents are welcome at any time
Decor in the common areas is clean, attractive, and acceptable to you
You feel comfortable within this environment
Physical Features Yes No
The building is designed to meet resident needs
The floor plan is easy to follow
Doorways and hallways are accommodating to wheelchairs and walkers
If applicable, elevators are available for those who can’t use the stairs
Hand rails are available to aid in walking
Cupboards and shelves are easy to reach
Floors are of a non-skid material and carpets are firm and secure
Lighting is good
Appropriately heated and cooled
Exits are clearly marked
Doors and windows are lockable
There are no noticeable hazards to your safety
Emergency response information posted
Individual Unit Features Yes No
Are different sizes and types of units available?
Are units for single and double occupancy available?
Can couples live together in the same room?
Do you have any input about your roommate assignment, if applicable?
Do residents have their own lockable doors?
Is a 24-hour emergency response system accessible from the unit?
Are bathrooms private?
Do bathrooms accommodate wheelchairs and walkers?
Do bathrooms have grab bars?
Are residents allowed to bring their own furnishings?
Do all units have a telephone?
Do all units have cable TV? (inquire about billing if the answer is yes)
Do residents have kitchen units or access to a common kitchen?
May residents keep food in their units?
Is smoking allowed? (In rooms? In common areas?)
Food Service Yes No
Three nutritionally balanced meals are provided daily, seven days/week
May a resident request special foods?
Are common dining areas available?
Are dining areas clean?
May residents eat their meals in their units?
Is there a set time for meals or may a resident decide when to eat?
Food looks good
Food smells good
Food portions look appropriate
Social and Recreational Activities Yes No
Is there evidence of an organized activities program, such as a posted
schedule, events in progress, reading materials, etc.?
Do residents participate in activities outside of the facility?
Do volunteers, including family members, help with or conduct activities?
Are residents required to participate in activities?
Are residents’ pets allowed to live in the facility?
Are residents’ pets allowed to visit in the facility?
Does the facility have a resident pet?
Is transportation provided to other facilities for activities?
Is transportation provided within the community as needed?
Are provided activities in line with what you enjoy?
Do you think you would be comfortable interacting with the residents?
Medication, Health Care, and Needs Assessment Yes No
Residence has specific policies regarding medication such as, storage
of, assistance with, training of staff, supervision of staff, and record keeping
Is self-administration of medication allowed?
A staff person is available to coordinate home care visits from a nurse, physical therapist, etc.
Trained staff is available to assist residents who experience memory, orientation, or judgment losses
A physician or nurse regularly visits the residents
Residence has a clearly stated procedure for responding to a resident’s medical emergency
A list of all offered services is provided
Staff is available to provide 24-hour assistance with activities of
daily living (dressing, eating, mobility, hygiene, grooming, bathing, etc.)
Transportation to Doctor appointments is provided
Housekeeping service for individual units is provided
Pharmacy, barber/beautician and/or physical therapy services are offered on-site or transportation can be arranged with short notice
Written plan of care for each resident
Residence has a process for assessing a potential resident’s need for services
Residence has a process for ensuring needs and services are reevaluated periodically
The process includes the resident, his or her family, facility staff, and the resident’s physician
There is sufficient staff to meet the resident’s needs
Contracts, Costs, and Finances
May a contract be terminated?
Is there refund language in the contract?
Are other sources of money available to help pay for service such as government, private, or corporate programs?
If the resident’s needs change, would additional services be available?
If nursing care or other care is needed on a temporary basis, is there a method in place to pay for these services?
Are there different costs for various levels or categories of service?
Are residents required to purchase renters’ insurance for personal property in their units?
Are there any other fees or charges?